Continuous or Interrupted Chest Compressions RCT

January 28, 2017

On the Shoulders of Giants

Push it real good
Continuous chest compressions have been a strong emphasis of ACLS training for almost a decade.  It makes sense from a physiology standpoint that interruptions precipitously drop coronary perfusion pressure.  But do brief interruptions to allow for rescue breaths impact survival?  This was a large cluster randomized trial of over 23,000 patients who had continuous compressions vs usual CPR (with brief interruptions to allow rescue breaths with a compression to breath ratio of 30:2) that found no difference in survival to hospital discharge.  Some have pointed out that overzealous bagging in the continuous compression group, which is known to be deleterious, may have been an unrecognized confounder, as they did not measure the number of breaths delivered to each group.

Spoon Feed
A pause in compressions to give rescue breaths vs continuous CPR with asynchronous breaths made no impact on survival to hospital discharge.

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Abstract

N Engl J Med. 2015 Dec 3;373(23):2203-14. doi: 10.1056/NEJMoa1509139. Epub 2015 Nov 9.

Trial of Continuous or Interrupted Chest Compressions during CPR.

Nichol G, Leroux B, Wang H, Callaway CW, Sopko G, Weisfeldt M, Stiell I, Morrison LJ, Aufderheide TP, Cheskes S, Christenson J, Kudenchuk P, Vaillancourt C, Rea TD, Idris AH, Colella R, Isaacs M, Straight R, Stephens S, Richardson J, Condle J, Schmicker RH, Egan D, May S, Ornato JP; ROC Investigators.

Comment in

• Continuous or Interrupted Chest Compressions during CPR. [N Engl J Med. 2016]
• Continuous or Interrupted Chest Compressions during CPR. [N Engl J Med. 2016]
• Cardiac resuscitation: Continuous chest compressions do not improve outcomes. [Nat Rev Cardiol. 2016]
• Continuous or Interrupted Chest Compressions for Cardiac Arrest. [N Engl J Med. 2015]
• Continuous or Interrupted Chest Compressions during CPR. [N Engl J Med. 2016]
• Continuous or Interrupted Chest Compressions during CPR. [N Engl J Med. 2016]
• Continuous or Interrupted Chest Compressions during CPR. [N Engl J Med. 2016]
• Continuous or Interrupted Chest Compressions during CPR. [N Engl J Med. 2016]
• Continuous or Interrupted Chest Compressions during CPR. [N Engl J Med. 2016]

Abstract

BACKGROUND:

During cardiopulmonary resuscitation (CPR) in patients with out-of-hospital cardiac arrest, the interruption of manual chest compressions for rescue breathing reduces blood flow and possibly survival. We assessed whether outcomes after continuous compressions with positive-pressure ventilation differed from those after compressions that were interrupted for ventilations at a ratio of 30 compressions to two ventilations.

METHODS:

This cluster-randomized trial with crossover included 114 emergency medical service (EMS) agencies. Adults with non-trauma-related cardiac arrest who were treated by EMS providers received continuous chest compressions (intervention group) or interrupted chest compressions (control group). The primary outcome was the rate of survival to hospital discharge. Secondary outcomes included the modified Rankin scale score (on a scale from 0 to 6, with a score of ≤3 indicating favorable neurologic function). CPR process was measured to assess compliance.

RESULTS:

Of 23,711 patients included in the primary analysis, 12,653 were assigned to the intervention group and 11,058 to the control group. A total of 1129 of 12,613 patients with available data (9.0%) in the intervention group and 1072 of 11,035 with available data (9.7%) in the control group survived until discharge (difference, -0.7 percentage points; 95% confidence interval [CI], -1.5 to 0.1; P=0.07); 7.0% of the patients in the intervention group and 7.7% of those in the control group survived with favorable neurologic function at discharge (difference, -0.6 percentage points; 95% CI, -1.4 to 0.1, P=0.09). Hospital-free survival was significantly shorter in the intervention group than in the control group (mean difference, -0.2 days; 95% CI, -0.3 to -0.1; P=0.004).

CONCLUSIONS:

In patients with out-of-hospital cardiac arrest, continuous chest compressions during CPR performed by EMS providers did not result in significantly higher rates of survival or favorable neurologic function than did interrupted chest compressions. (Funded by the National Heart, Lung, and Blood Institute and others; ROC CCC ClinicalTrials.gov number, NCT01372748.).

PMID: 26550795 [PubMed – indexed for MEDLINE]